the influence of culture on diagnostics 2

The Influence of Culture on Diagnostics

Analysis of the use of the Cultural Formulation in Diagnosis

Hans Rohlof, Simon Groen, Rob van Dijk, Richard Starmans

April 13, 2023 The Influence of Culture on Diagnostics. Hans Rohlof et al 2

Stichting Centrum ’45

• The national institute for specialist diagnostics and the treatment of people with complex psychotrauma complaints

• These complaints have a broad background:– Result of persecution and / or war– Result of repeated / job-related violence60 % of the patients are refugees from 45

different countries.

Rijnzichtweg 352342 AX

Oegstgeest071 5191500

Locations Centrum ‘45

Registration and Information Office 0800 2 245 245

Nienoord 51112 XE Diemen020 6274974


The Cultural Formulation of Diagnosis (CF)

• Need of more sensitive diagnostics in different ethnic groups

• Use of CF in assessment procedure• Initial version of Cultural Interview (CI)• Book in Dutch to promote use of CF

Content of cultural formulation

• Cultural identity of the individual• Cultural explanation of the individual’s

illness• Cultural factors related to psychosocial

environment and levels of functioning• Cultural elements of the relationship

between the individual and the clinician


Culture, classification and diagnostics

Use of the Cultural Formulation in Refugees

• Article (2009) in Transcultural Psychiatry• Description of Cultural Interview as used

in our clinic• Specific adaptation of the CF for

refugees



The Cultural Formulation of Diagnosis (CF)

Developed on the basis of anthropological theories

Attached as a chapter in DSM-IVMostly unknown by diagnosing mental health

workers Lack of sufficient practical applicability


Theoretical backgrounds

• cultural identity complex, but important with regard to expression of emotions and physician-patient-relationship

• Idioms of illness, illness explanations and help seeking behavior are important in indications of treatment

• social interactions important: social element of illness

• Frequent misinterpretation of resources and level of functioning.

• Diagnosis has to be reliable but also valid


Research before DSM-IV

• APA committee on cross-cultural issues: 45 transcultural experts and 15 DSM-experts

• Field trial with 4 large ethnical groups in the U.S.A.: African Am, Hispanics, Asians, Natives


Literature search

• The terms: ‘cultural formulation’ and ‘cultural consultation’ related to ‘mental’ in PubMed (1994-present).

• 112 research articles and describing articles, and 28 case histories.


• What is the status of implementation research on the CF?• How can the CF be implemented more uniformly? Have implementation

guidelines been proposed? If not, which may be recommended?• What is the status of empirical effectiveness research on the impact of

the CF…– On diagnostic validity or reliability?– On clinical response?– In terms of cost effectiveness?

• What is the status of research on making the CF more efficient and disseminatable (i.e., simpler, shorter) without sacrificing its value as a narrative, comprehensive assessment?

• How can the usefulness of the CF for every clinical encounter be emphasized, as opposed to the perceived use of the CF as applicable only in cross-cultural interactions or for “exotic” patients?

• About the summary of the CF: What proposals have been made or tested to better systematize this application to facilitate dissemination and training?

• Are there data on adapting the CF specifically for refugees, as opposed to migrants more generally?

Questions asked


Status of implementation research 28 articles, in which was described the use of the

CF in different clinical populations.describing articles interesting for therapists who

treat patients from the described population In The Netherlands important in the education in

transcultural mental health care: mental health psychologists, psychiatrists (new curriculum). Also in the education of general practitioners.


Guidelines & clinical interviews

EMIC (Weiss, 1997): focused on illness experience.

Manual of Cultural Psychiatry (Lim, 2006)McGill Illness Narrative- MINI (Groleau,

2006): focused on illness explanation.Cultural Interview (Rohlof e.a., 2002):

semi-structured interview; 90 minutes.Short cultural interview (Groen, 2008): 30

minutes


Status of research

Qualitative studies in NL:Borra et al (2002): improvement of diagnostic

process, but danger of instrumentalisation without improvement of cultural competencies.

Starmans (2005): no diminishment of gap between GP and patient but also no sign of not accepting the status of the GP.

Beijers and Tempelman (2009): in mental health care diminishment of gap between patient and therapist.


Status of researchQuantitative studies:Lopez-Appelo (2000): research in Latin American patients

(n=1003), divided in two groups, one with CF: success of treatment better in CF-group.

Neighbors et al (2003): with using the CF African American wer less frequently diagnosed with schizophrenia.

Zandi et al (2008): more agreement with clinical diagnosis when adding the CF to the CASH-questionnaire in Moroccan patients.

Harris et al, Kirmayer et al: more cultural competency in treatment when using the CF

Ton (2005): investigation of all cultural sensitive services in the U.S.A. Ethnic matching impossible, CF meaningful


CF shorter, more applicable?

Most important items:• Cultural identity: origin, ethnicity,

acculturation, self image, gender.• Cultural illness explanations: awareness of

illness, illness explanations, religious aspects.

• Social network: position of the family, contacts with relatives, other social contacts, the role of shame, stigmatisation.

CF is also important for the relation with the patient: more adherence to therapy.


CF also for native patients?

Better: Contextual Formulation of Diagnosis:1. Social factors: social economical status,

housing, discrimination, accessibility of care. Family backgrounds.

2. Juridical factors: procedures, permit to stay.

3. Cultural factors: language, culture differences, migration history.


Systematisation of summary

Acculturation and quality of life can be quantified(Mezzich, 2008).

Describing cultural elements in terms of problems and possibilities (Rohlof, 2008).

Calling culture a process, also in therapy (van Dijk et al, 2002).


Adaptations for refugeesAcharya (2009): No adaptations but CF considered as

important because of differences in self concept, diffrences in concept of stress involvement and stigmatisation and differences in symptom expression.

Rohlof et al (2009): adaptations: working with interpreters, attitude towards own culture of therapist and patient, discrimination and accessibility of care. Next to this cultural interview.

Groen (2008): improvement of diagnostics and treatment by interview.


Conclusions and advices for DSM-V

Attention to self concept en identityAttention to illness explanationsMigration historyDiscrimination and inaccessibility of careStigmaSocial, economical and juridical factors. In short:


Attention toContextual Formulation of Diagnosis


More information about CF and CIwww.rohlof.nlwww.centrum45.nl

04/13/23 T I T E L V A N D E P R E S E N T A T I E 24

www.centrum45.nl

the influence of culture on diagnostics 2

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